Grant Programs Directorate
OMB Control#: 1660-0115
Expiration Date: 10/31/2013
FEMA Form: 024-0-1
DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
ENVIRONMENTAL AND HISTORIC PRESERVATION SCREENING FORM
Paperwork Burden Disclosure Notice
Public reporting burden for this form is estimated to average 8 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You are not required to respond to this collection of information unless it displays a valid OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660- 0115) NOTE: Do not send your completed form to this address.
Completing the Screening Form:
This form must be attached to all project information sent to the Grant Programs Directorate (GPD) to initiate environmental and historic preservation (EHP) compliance review, per the National Environmental Policy Act (NEPA) and other EHP laws and executive orders. There is no need to complete and submit this form if the grant scope is limited to planning, management and administration, classroom-based training, table-top exercises and functional exercises, or purchase of mobile and portable equipment where no installation needed. Information Bulletin 345 (September 1, 2010) provides details on these activities. The form must be completed by someone with in-depth understanding of project details and location. Completion of this form does not conclude the EHP review process and FEMA may need to contact you for further information. Not providing requested information may result in funding release delays. This form is intended to be completed electronically. The following website provides a version of this form that is suitable for printing and completing by hand as well as additional guidance such as on how to make an aerial map: http://www.fema.gov/plan/ehp/ehp-applicant-help.shtm#5.
To check (X) a box (for example, Yes No), left double-click using your mouse and a Check Box Form Field Options box will appear, then under the Default Value, select Checked and press OK (see figure, right). To write in a text field (), select the text field with your mouse and begin typing.
Submit completed form with necessary attachments to the State Administrative Agency with the following information in the e-mail subject line:EHP Submission: Project Title, Subgrantee Name; Grant Award Number (Example, EHP Submission: Courthouse Camera Installation, Any Town, State, 12345).
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Environmental and Historic Preservation Screening Form
Complete all of Section A, Section B, all of each portion(s) of Section C corresponding to checked blocks in Section B, and all of section D that apply to the project.
A. PROJECT INFORMATION (complete all)
DHS Grant Award Number: Grant Program:
Fiscal Year:
Project Title:
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Environmental and Historic Preservation Screening Form
Grantee (SAA):
Grantee POC:
Mailing Address:
E-mail:
Sub grantee:
Subgrantee POC:
Mailing Address:
E-mail:
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Environmental and Historic Preservation Screening Form
Dollar value of grant (if known):
B. PROJECT TYPE
Please check ALL the block(s) that best fit the scope of the project.
1. Training and Exercises. Go to page 2. Complete all of Section C.1.
2. Purchase of Equipment. Go to page 3. Complete all of Section C.2.
3. Physical security enhancements. Go to page 3. Complete all of Section C.3.
4. Renovations/upgrades/modifications to existing structures. Go to page 3. Complete all of Section C.4.
5. New construction/addition. Go to page 4. Complete all of Section C.5.
6. Communication towers, related equipment, and equipment shelters. Go to page 5. Complete all of Section C.6.
7. Other. If your project does not match any of these categories, go to page 6. Complete Section C.7
The following information is required to initiate EHP review of the project. Based on the project’s scope of work, determine which project type applies below and complete that section. For multi-component projects or those that may fit into multiple project types, complete the section that best applies and provide a complete project description. The project description should contain a brief summary of what specific action is proposed, where it is proposed, and how it will be implemented. If the project involves multiple locations, information for each must be provided. Attach additional pages, if needed.
Provide a complete project description:
C. PROJECT DETAILS
1. Training and Exercises (check each that applies): Classroom-based Field-based
If the training is classroom and discussion-based only, and is not field-based, this form does not need to be completed and submitted. All other training must provide the following:
a. Describe the scope of the proposed training or exercise (purpose, frequency, materials,
and equipment needed, number of participants, and type of activities required)
(Attach additional pages, if needed):
b. Will the field-based training take place at an existing facility having established procedures for that particular proposed training and exercise, and that conforms with existing land use designations (refer to Information Bulletin #329 (http://fema.dps.mo.gov/empg/IB%20329_20090902.pdf) for further information)? Yes No
· If yes, please provide the name and location of the facility (physical training site
address or latitude-longitude):
· If no, provide the location (physical project address or latitude-longitude) and a full
description of the area where training will occur:
c. Does the field-based training/exercise differ in any way (including, but not limited to frequency, amount of facilities/land used, materials or equipment used, number of participants, type of activities) from previously permitted training exercises and training practices? Yes No
· If yes, explain any differences between the proposed activity and those that were
approved in the past, and the reason(s) for the change in scope:
d. Will any equipment or structures need to be installed to facilitate training? Yes No
· If yes, explain how and where this is proposed to be done (include site-specific color
photographs:
2. Purchase of equipment (If the entire project is limited to purchase of mobile/portable equipment and there is no installation needed, you do not need to complete and submit this form.)
a. Specify what equipment, and the quantity:
b. Provide AEL number(s) (if known):
c. Will this equipment be installed? Yes No
· If Yes, go to page 6. Complete Section D.
3. Physical security enhancements and or installations (for example: installation of back-up generators, fencing, cameras, building/room access control, bollards, motion detection systems, x-ray machines, and lighting).
a. Describe what, how, and where improvement(s)/installation(s) will occur in/on the
facility/building/structure:
b. Provide project location (physical project address and latitude-longitude):
c. Will the new equipment/improvements use the existing power supply systems? Yes No
· If no, describe new power source and installation (such as utility trenching):
d. If generator installation, please state the capacity (KW):
· If a separate fuel tank is also included, describe if it is to be installed above or below
ground, and its capacity (gallons):
e. Go to Page 6. Provide additional project details in Section D.
4. Renovations/upgrades/modifications to existing structures.
a. Provide detailed description of modifications:
b. Provide project location (physical project address and latitude-longitude):
c. Will any equipment need to be installed? Yes No
· If yes, please note in Section 2, (purchase of equipment).
f. Go to Page 6. Provide additional project details in Section D.
5. New construction/addition (for example: emergency operations centers, docks, piers, security guardhouse).
a. Provide detailed scope of work (site acreage, new facility square footage/number of stories,
utilities, parking, stormwater features, etc):
b. Provide project location (physical project address or latitude-longitude):
c. Will any equipment need to be installed? Yes No
· If yes, please note in Section 2 (purchase of equipment).
d. Will the new building/facility/renovations use existing utilities? Yes No
· If no, describe installation of new utilities in (a) above (including trenching):
e. Go to Page 6. Provide additional project details in Section D.
6. Communication towers, related equipment, and equipment shelters
a. Provide a detailed description of the project
b. Provide project location (physical project address or latitude-longitude:
c. Provide the elevation above mean sea level of the project location:
d. For projects involving antenna(s) installations on existing towers:
· Provide the height of the existing tower:
· The height of the tower following the installation of the new antenna(s):
e. For new tower projects, state the total height (in feet) of the communication tower or
structure including any antennae to be mounted:
· If the proposed tower height is greater than 199 feet above ground level, state why
this is needed to meet the requirements of the project:
· Will the tower be free-standing or require guy wires? Free standing Guy wires
· If guy wires are required, state number of bands and how many:
· State why a guyed tower is needed to meet the requirements of this project:
· What kind of lighting will be installed, if any (for example: white strobe, red strobe,
or steady burning?):
f. A general description of terrain (For example: mountainous, rolling hills, flat to
undulating):
g. Describe the frequency and seasonality of fog/low cloud cover:
h. Provide a list of habitat types and land use on and adjacent to the tower site (within ½ mile),
by acreage and percentage of total (e.g., woodland conifer forest, grassland, agriculture)
waterbody, marsh):
i. Is there evidence of bird roosts or rookeries present within ½-mile of the proposed site? Yes No
a. If yes, describe:
· Distance to nearest wetland area (for example: forested swamp, marsh, riparian, marine)
and coastline if applicable:
i. Distance to nearest telecommunication tower:
j. Have measures been incorporated for minimizing impacts to migratory birds? Yes No
· If yes, describe:
k. Has an FCC registration been obtained for this tower? Yes No
· If yes, provide Registration #:
l. Has the FCC E106 process been completed? Yes No
m. Has the FCC Tower Construction Notification System (TCNS) process been completed? Yes No
· If yes, attach all relevant environmental documentation submitted as part of the
registration process including use of the Tower Construction Notification System
(TCNS), if applicable. FRN#
n. Will any equipment or structures need to be installed? Yes No
· If yes, explain what type how and where this is proposed to be done (attach additional
pages, if pages needed):
o. Will equipment be co-located on existing FCC licensed tower or other structure? Yes No
· If yes, identify the type of structure:
p. Go to Page 6. Provide additional project details in Section D.
7 . Other. For any project that does not fit a category listed above, please provide a thorough summary of the proposed action and location. Include as much detail as necessary to ensure someone not personally familiar with the project is able to conduct an EHP review.
a. Project Summary:
b. Provide additional project details in Section D.
D. OTHER PROJECT RELATED INFORMATION (complete all that apply)
The following website may provide some additional EHP related guidance and resources to help complete this section http://www.fema.gov/plan/ehp/ehp-applicant-help.shtm#5.
1. If work is proposed on/in an existing building(s) or structure(s) provide the year built:
· If the building or structure involved is over 45 years old and significant renovation,
rehabilitation, or modification has occurred, please provide the year(s) and briefly
describe the nature of remodeling:
2. If the project affects the exterior of the building, are there any known buildings and/or structures that are 45 years or older in the immediate project area? Yes No/NA
· If yes, please provide the location, ground-level color photos of these, and identify their location(s) on the aerial map.
3. Is the building or structure on which work is proposed a historic property or in a historic district, or are there any adjacent historic properties? Yes No
· Information about historic properties may be found on the National Register of Historic Places at http://nrhp.focus.nps.gov/natreghome.do?searchtype=natreghome or the respective State Historic Preservation Office may have information on their website.
4. Will ground disturbance be required to complete the project? Yes No
· If yes, provide total extent (depth, length and width) of each unique ground disturbing
activity. Light poles, bollards and fencing are each unique ground disturbing activities
(For example, six light poles, 24” dia. x 4’ deep; trenching 12” x 500’ x 18" deep):
5. Has the ground been previously disturbed? Yes No
· If yes, please describe the current disturbed condition of the area (for example, parking
lot, roadway right-of-way, commercial development):
6. Are there technical drawings or site plans available, if yes please attach. . Yes No
7. Attach color site photographs:
· Ground-level color site photos that provide context and show where site work/physical
installations are proposed (label photos),
· Ground-level color photographs of each side of the building involved.
· Aerial color photograph with project limits outlined and with the location of any
proposed installations identified.
· Aerial color photograph(s) showing all ground disturbing activities (if applicable).
8. Is the project part of an approved plan such as a Master Plan or an Implementation Plan or any larger action/project? Yes No
· If yes, provide the plan/project name and brief description:
9. Is there any previously completed environmental documentation for this project (for example: Environmental Impact Statement, Environmental Assessment, wetland delineation, archaeological study)? Yes No
· If yes, please attach documentation. If a NEPA document, what was the decision? (Check one, and please attach):
Finding of No Significant Impact (FONSI) or
Record of Decision (ROD)
Name of preparing agency:
Date approved:
10. Is there any previously completed agency coordination for this project (for example correspondence with the U.S. Fish and Wildlife Service, State Historic Preservation Office (SHPO), Tribal Historic Preservation Office (THPO), or permitting agencies? Yes No